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Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Mac. Lab. Monitoring Date : __________________
Merk : MARQUET Period : __________________
Serial No. : _________________________ Room : __________________
Display housing ___________________________________
Computer module housing ___________________________________
Line / Power plug ___________________________________
Line / Power cord ___________________________________
Display fuse holder ___________________________________
System cables at rear of Display & ___________________________________Computer Module
Cable connectors ___________________________________
Rack & Parameter Module connectors___________________________________
Labeling and accessories ___________________________________
Patient safety checks ___________________________________
Indicators on / off and screen ___________________________________
LEDs on the parameter Module ___________________________________
Display performance ___________________________________
Visual and audible Alarm ___________________________________
Self-check procedures ___________________________________
Test Equipment Used : ECG Stimulator BIOTEK, Fluke multi meter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment :PROCCESING FILM Date : __________________
Merk :KODAK Period : __________________
Serial No. : _________________________ Room : RADIOLOGI
Film Guide Assembly ____________________________________
Detector/Crossover Assemblies ____________________________________
Rollers ____________________________________Gears ____________________________________Guide Shoes ____________________________________Bearings ____________________________________Brackets ____________________________________Nuts ____________________________________
Squeegee Assembly ____________________________________
Rollers ____________________________________Gears ____________________________________Guide Shoes ____________________________________Bearings ____________________________________Brackets ____________________________________Nuts ____________________________________
Rack Assembly ____________________________________
Rollers ____________________________________Sprockets ____________________________________Chain ____________________________________Springs ____________________________________Rewet Rollers ____________________________________
Turnaround Assembly ____________________________________
Rollers ____________________________________Tubing ____________________________________
____________________________________
Main Drive Assembly ______________________________________________________________________
Plumbing ___________________________________
Connections ___________________________________Tubing ___________________________________
___________________________________
Recirculation System ___________________________________
Filter ______________________________________________________________________
Developer Temperature___________________________________
___________________________________
Water Flow to the Processor ______________________________________________________________________
Chemical Replenisher ______________________________________________________________________
Strainer Assembly ______________________________________________________________________
Dryer Section ___________________________________
Bearing ___________________________________Air Tube ___________________________________Roller ___________________________________O-Rings ___________________________________
Dryer Temperature ___________________________________
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Electrocardiograph Date : __________________
Merk : Period : __________________
Serial No. : _________________________ Room : __________________
Visual Inspection : Disconnect the cardiograph form AC power and inspect for theFollowing :
L Loss or missing hardware ____________________________
Frayed or damage wiring ____________________________
Mechanical damage ____________________________
Evidence of liquid spill ____________________________
Printer drive gear wear ____________________________
Printer roller wear ____________________________
Wear or damage to power cord andAssociated strain relief ____________________________
Corroded or damage electrodes ____________________________
Damage lead wires or patient module cable
____________________________
Dirt on thermal printer head ____________________________
Connect the cardiograph to AC power and turn on the AC switch.Verify the following :
The AC indicator is lit ____________________________
One or more green battery indicator are lit when On-Standby is
pressed
Turn on the cardiograph ____________________________
Extended Self-test : Run Extended self-test, select “ALL” menu choice and verify that
each test passes with no errors.
Patient module and cable ____________________________
CPU assembly ____________________________
Printer ____________________________
Preview display ____________________________
Keyboard display ________________________
Electrocardiograph Simulation : Record an ECG wave using an ECG simulator. Verify the following :
Trace activity for all 12 leads
No gross distortion of complexes or calibration pulses
Calibration pulses are of proper duration (200 ms) and amplitude (1
mV)
The trace will vary depending on simulation setting used and simulation type.calibration pulse measurements will vary depending on the cardiograph gain
and speed setting.
Comments : ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Pulse Recorder :
Test Equipment Used : ECG Stimulator BIOTEK, Fluke multi meter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Treadmill Date : __________________
Merk : _________________________ Period : __________________
Serial No. : _________________________ Room : __________________
Visual Inspection: Inspect the following for excess wear and/ or any visual signs of damage.
_____ Walking belt ____AC power cord _____ Internal cable and connectors
_____ Interface cable ____ Handrail hardware _____ Socketed components
_____ Drive beltCleaning___ use anti septic cleaner on the following areas: ___ Handrails ___ Shroud ____ Walking beltPower Supplies/Diagnostic test
-7.5 V dc ( 0,75) ____ Volts +16,5 V dc ( 1,65) ___Volts+5 V dc ( 0,5) ____ Volts +5 V -ISO ( 0,5) ___ Volts Speaker ___
Self calibration Speed calibration (2 mph)____mph (10 revolution in 38 seconds) Grade calibration (10 %) ____%
Electrical safety test AC line voltage test
___ Line to Neutral= 220 V Ground___ Line to Ground= 220 V ___ Neutral to Ground (< 3V) Neutral Line
Leakage testGround wire leakage to ground (100 uA max) Open ClosedChassis leakage to ground (exposed chassis) Normal Reversed Normal Reserved(100 uA max) NA NA ____uA ____uA
___uA ___uA NA NA Ground Continuity test
Ground pin to chassis ___ <0.1 ohmEnvironment
Room temperature_____(C) Humidity_____%Operational TestApply power to the Treadmill_____ Increase and decrease speed from minimum to maximum_____ Depress the emergency stop button (if attached ) while walking belt is spinning to confirm proper
operation _____ Raise and lower elevation from 0% to 25%._____ This completes the operational test.
Test Equipment Used : Tacho meter , Electric Safety Analyzer, ECG Stimulator
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
LAPORAN PEMERIKSAAN ALAT BARU
Equipment : PATIENT MONITOR
Merk : ____________________ Date : __________________
Serial No. : _________________________ Room : __________________
Display housing ___________________________________
Computer module housing ___________________________________
Line / Power plug ___________________________________
Line / Power cord ___________________________________
Display fuse holder ___________________________________
System cables at rear of Display & ___________________________________Computer Module
Cable connectors ___________________________________
Rack & Parameter Module connectors ___________________________________
Labeling and accessories ___________________________________
Patient safety checks ___________________________________
Indicators on / off and screen ___________________________________
LEDs on the parameter Modules ___________________________________
Display performance ___________________________________
Visual and audible Alarm ___________________________________
Self-check procedures ___________________________________
Test Equipment Used : ECG Stimulator BIOTEK, Fluke multi meter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Electrocardiograph Date : __________________
Merk : Nihon kohden Period : __________________
Serial No. : _________________________ Room : __________________
Visual Inspection : Disconnect the cardiograph form AC power and inspect for theFollowing :
L Loss or missing hardware ____________________________
Frayed or damage wiring ____________________________
Mechanical damage ____________________________
Evidence of liquid spill ____________________________
Printer drive gear wear ____________________________
Printer roller wear ____________________________
Wear or damage to power cord andAssociated strain relief ____________________________
Corroded or damage electrodes ____________________________
Damage lead wires or patient module cable
____________________________
Dirt on thermal printer head ____________________________
Connect the cardiograph to AC power and turn on the AC switch.Verify the following :
The AC indicator is lit ____________________________
One or more green battery indicator are lit when On-Standby is
pressed
Turn on the cardiograph ____________________________
Extended Self-test : Run Extended self-test, select “ALL” menu choice and verify that
each test passes with no errors.
Patient module and cable ____________________________
CPU assembly ____________________________
Printer ____________________________
Preview display ____________________________
Keyboard display ________________________
Electrocardiograph Simulation : Record an ECG wave using an ECG simulator. Verify the following :
Trace activity for all 12 leads
No gross distortion of complexes or calibration pulses
Calibration pulses are of proper duration (200 ms) and amplitude (1
mV)
The trace will vary depending on simulation setting used and simulation type.calibration pulse measurements will vary depending on the cardiograph gain
and speed setting.
Comments : ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Pulse Recorder :
Test Equipment Used : ECG Stimulator BIOTEK, Fluke multi meterRemarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Hypo/Hyperthermia Blanket Date : __________________
Merk : _________________________ Period : __________________
Serial No. : _________________________ Room : __________________
1. External cabinet and control panel in good condition.
______________
2. All warning labels properly affixed. ______________
3. Quick disconnect coupling (tight, straight, not leaking)
______________
4. Power Cord (no cuts or exposed wire) and ______________
plug no (bent or missing pin)
5. Indicator lights (heat & cool , compressor, heaters, pump, power)
______________
6. Drain and clean reservoir ______________
7. Clean water filter ______________
8. Refill reservoir with distilled or sterile water
______________
9. Leakage current check ( all reading should be under 110 A for
______________
115/110 Volt AC and 500A for 230/240 Volt AC ) ______________
OFF normal polarity _____________________OFF reverse polarity _____________________ON normal polarity (heat) _____________________
ON reverse polarity (heat) _____________________ON normal polarity (cool) _____________________ON normal polarity (cool) _____________________
10 . Condition of blanket, hoses, coupling (check for leaks)
______________
11. Refrigerant test : a. Clean condenser and fan ______________
b. Check sight glass ______________
12. Check temperature ( high / low and limit) _______________________________
_______________________________
Test Equipment Used : DPM 3 Temp test, multi meter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : ELECTROSURGICAL Date : __________________
Merk : Period : __________________
Serial No. : _________________________ Room : __________________
Calibration / Verification Checklist
S/N Physical/ Qualitative Test Pass Fail Electro surgical Quantitative Test
1 Chassis / Mounts/Fasteners A. Pure Cut Levels
2 Controls/Switches Selected Delivered ( Watts) Tolerance ( Watts)
3 Fittings/Connector 10 375 ±25
4 Cables/Accessories 7 245 ± 30
5 Indicators/Displays 5 160 ± 30
6 Foot Switch 2 35 ± 20
7 Isolation Switch B. Blends Levels
8 Low Frequency Output Selected Delivered ( Watts) Tolerance ( Watts)
9 REM Circuit 10 250 ±25
10 Cooling Fan Test 7 140 ±40
11 Power On Switch and Circuit Breaker 5 95 ± 20
2 25 ± 15
C. Coag Levels
Selected Delivered ( Watts) Tolerance ( Watts)
10 125 ± 15
7 75 ± 10
5 45 ± 10
2 10 ± 5
Test Equipment Used : RF 302 Electro surgical Analyzer
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : DEFIBRILATOR
Date :___________________________
Merk : ________________ Period :__________________________
Serial No. : ___________________ Room :__________________________
No Physical/Quantitative Test Pass Fail Calibration / Verification Checklist Koreksi
Defibrillator Quantitative Test
1 Chassis/Mounts /Fasteners Selected Delivered ( J ) Tolerance ( J )
2 Controls/Switches 10 8 - 12
3 Fittings/Connectors 20 16 - 24
4 Cables/Accessories 50 45 - 57
5 Battery/Charger 100 85 - 115
6 Indicator/Display 200 170 - 230
7 Alarms/Audible Signals 300 225 - 345
8 Recorder/Printer 360 306 - 414
9 Cardio version Test Paper Speed 25mm / 50 mm
10 Defib Paddles Int. Cal.Test Deliver
11 Safety Checks 100 Joule
12 Internal Cal. Test
Ket : J dalam satuan JOULE
Test Equipment Used : Defibrilator Analyzer QED 6
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. EngPreventive Maintenance Checklist
Equipment : Ventilator Date : _____________________
Merk : _________________________ Period : _____________________
Serial No. : _________________________ Room : _____________________
PPM CHECKLIST S/N Calibration/ Verification checklist Pass FailS/N Physical/Qualitative test Pass Fail 9 Tidal Volume
1 Chassis/Mounts/Fasteners 10 Total Rate 2 Controls/Switches 11 I : E Ratio 3 Fitting / Connectors 12 Manual Breath 4 Cable / Accessories 13 Alarm Silence 5 Battery / Charger 14 Expiration Time / Led 6 Indicator / Displays 15 Apnea Time 7 Alarms / Audible signals 16 Preset
17 Pressure (Peak, Mean,& Base) Calibration / Verification Checklist 18 Mode Selector
1 Flow 19 Trigger level a. Spontaneous Flow 20 Low Pressure Alarm B Main Flow 21 High Pressure Alarm
2 Respiratory Rate 22 External power Off/ 3 Inspiratory Time Power Disconnect Alarm 4 A/C Sigh 23 Battery power
5 Nebulizer 24 Low Battery Alarm 6 Peep 25 System Failure Alarm 7 Peak Inspiratory Pressure (PIP) 26 Fl O2 8 Leakage Test 27 Hour meter
Test Equipment Used : RT – 200 Calibration Analyzer
Remarks : ___________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/
Biomedical. EngPreventive Maintenance Checklist
Equipment : Timbangan Bayi Date :
_____________________
Merk : SECA Period : _____________________
Serial No. : _________________________ Room : _____________________
Massa Nominal (g) Hasil Pembacaan(g) Toleransi (g)
5 _______________ 4,95-5,05
10 _______________ 9,9-10,1
50 _______________ 49,5-50,5
100 _______________ 99-101
500 _______________ 495-505
1000 _______________ 990-1010
5000 _______________ 4950-5050
10000 _______________ 9900-10100
Cek Fisik:
Battery :--------------------------------------------------------------------------------
Adaptor :--------------------------------------------------------------------------------
Pengukur tinggi :--------------------------------------------------------------------------------
Tare :-------------------------------------------------------------------------------
Display :-------------------------------------------------------------------------------
Test Equipment Used : ___________________________________________________________
Remarks : ___________________________________________________________
Performed by : _____________________ Verified by : ______________________
BM.0308.46
Biomedical. EngPreventive Maintenance Checklist
Equipment : Timbangan Date : _____________________
Merk : Period : _____________________
Serial No. : _________________________ Room : _____________________
Massa Nominal (kg) Hasil Pembacaan(kg) Toleransi (kg)
1 _______________ 0.99-1,01
5 _______________ 4,95-5,05
10 _______________ 9,9-10,1
20 _______________ 19,8-20,2
35 _______________ 34,65-35,35
50 ________________ 45,50-55,50
70 _______________ 69,3-70,7
100 ________________ 99-101
Cek Fisik:
Battery :--------------------------------------------------------------------------------
Adaptor :--------------------------------------------------------------------------------
Pengukur tinggi :--------------------------------------------------------------------------------
Tare :-------------------------------------------------------------------------------
Display :-------------------------------------------------------------------------------
Test Equipment Used : ___________________________________________________________
Remarks : ___________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Transport Incubator Date : __________________
Merk : _Datex Ohmeda_________ Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical/Quantitative Test Pass Fail
1 Chassis/Mounts /Fasteners
2 Controls/Switches
3 Fiitings/Connectors
4 Cables/Accessories
5 Battery/Charger
6 Indicator/Display
7 Alarms/Audible Signals
8 Air oxygen system
9 Temperature
10 Infant Chamber
11 Air Flow System
12 Tank Inspection
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : DOPPLER Date : __________________
Merk : _________________________ Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical/Quantitative Test Pass Fail
1 Chassis / Mounts / Fasteners
2 Controls / Switches
3 Fiitings / Connectors
4 Cables / Accessories
5 Battery / Charger , Vdc
6 Indicator / Display
7 Alarm / Audible Signals
8 Tranduser
9 Cabel + Conector Tranduser
10 Beep
11 Calibrasi
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM 0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Bed Pasien Date :
__________________
Merk : _________________________ Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical/Quantitative Test Pass Fail
1 Chassis / Mounts / Fasteners
2 Controls / Switches
3 Fittings / Connectors
4 Cables / Accessories
5 Indicator/Display
6 Hydraulic System
7 Brake System
8 Lubricating
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM 0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : NBP MONITOR Date : __________________
Merk : Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical/Quantitative Test Pass Fail
1 Chassis / Mounts / Fasteners
2 Controls / Switches
3 Fiitings / Connectors
4 Cables / Accessories
5 Battery / Charger , Vdc
6 Indicator / Display
7 Alarm / Audible Signals
8 Manset
9 Self Test
10 Pump
11 Calibrasi
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : FETAL MONITOR / CTG Date : __________________
Merk : _________________________ Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail
1 Chassis / Mounts / Fasteners
2 Controls / Switches
3 Fiitings / Connectors
4 Cables / Accessories
5 Battery / Charger , Vdc
6 Indicator / Display
7 Selft Test
8 Tranducer Test
9 Parameter Test
10 System Test
11 Printting Test
12 Beep
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. EngPreventive Maintenance Checklist
Equipment : Timbangan Date : _____________________
Merk : Precise Period : _____________________
Serial No. : _________________________ Room : _____________________
Kinerja
No Setting(gr) Terukur Toleransi (gr)1. 1 0,99-1,012. 2 1,98-2,023. 5 4,95-5,054. 10 9,9-10,15. 20 19,8-20,26. 50 49,5-50,57. 100 99-1018. 200 198-202
9. 500 495-50510. 1000 990-1010
Test Equipment Used : ___________________________________________________________
Remarks : ___________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. EngPreventive Maintenance Checklist
Equipment : Incubator Date : _____________________
Merk : Memmert Period : _____________________
Serial No. : _________________________ Room : _____________________
Kinerja
No Setting Suhu pada alat( C) Terukur Toleransi1. 37 36,63-37,372. 38 37,62-38,383. 60 59,4-60,6
Visual inspection Pass FailMain unit
AccessoriesCleaningFunction
Test Equipment Used : ___________________________________________________________
Remarks : ___________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. EngPreventive Maintenance Checklist Peruangan
Equipment : Tensimeter Date : __________________
Merk : _________________________ Period : __________________
Serial No. : _________________________ Room : __________________
No ITEM KEADAAN NORMAL KONDISI KETERANGAN
1 Pengecekan Fisik Kondisi baik dan bersih, tidak ada lumut/jamur, dan segala kelengkapan nya ada semua (manset, balon pompa, air raksa, tubing spiral)
2 Pengecekan Manset Kondisi karet manset baik tidak ada kebocoran
3 Pengecekan tabung, Tabung dan glass
glass dan air raksa manometer baik sehingga air raksa tidak ada yang tumpah/ tetap menunjuk di angka 0 )
4 Pengecekan Balon Pompa
Balon pompa tidak ada kebocoran, elastisitasnya baik, pentil angin dan valve-nya baik
5 Pengecekan tekanan Air raksa naik saat dipompa sampai angka tertinggi dan saat didiamkan tidak turun secara cepat
Test Equipment used : D P M 3
Remarks : ___________________________________________________
Performed by : __________________ Verified : ____________________
BM 0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Bed Pan Washer Date : __________________
Merk : Stand bridge Period: __________________
Serial No. : _________________________ Room : __________________
NO Physical / Quantitative Test Pass Fail
1 Water Supply (cold and Hot)
2 Float Switch
3 Break Tanks
4 Pump
5 Timer
6 Heater
7 Probes, Sensor, Thermostats
8 Start Button
9 Key Switch
10 Door Micro switch
11 Door Mechanism/seal
12 Indicator Lights
13 Foot Bellows and Air Switch
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM 0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Matras Decubitus Date : __________________
Merk : _________________________ Period : __________________
Serial No. : _________________________ Room : __________________
1. External cabinet and control panel in good condition.
______________
2. Pump.
______________
3. Quick disconnect coupling (tight, straight, not leaking)
______________
4. Power Cord (no cuts or exposed wire) and ______________
plug no (bent or missing pin)
5. Condition of Mattras -
______________
6. Indicator on/off
______________
Test Equipment Used : Tool set
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Phototherapy Lamp Date : __________________
Merk : Air-shields Period: __________________
Serial No. : _________________________ Room : __________________
NO Physical / Quantitative Test Pass Fail
1 Chassis/mounts/Fasteners
2 Controls/Switches
3 Fittings/Connectors
4 Cables/Accessories
5 Timer
6 Indicator/Display
7 Cooling Fan
8 Bulb
9 Light output Check ……………… uw/cm2
10 Cleaning
Test Equipment Used : Phototherapy Radiometer
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Eagle Ten Sterilizer Date : __________________
Merk : Amsco Period: __________________
Serial No. : _________________________ Room : __________________
NO Physical / Quantitative Test Pass Fail
1 Preparation
2 Door Assembly
3 Selenoid Valve
4 Over temperature Controller
5 Air Vent (Steam)
6 Gauge
7 Chamber & Water Reservoir
8 Control Components
9 Final Test
Test Equipment Used : DPM III, Fluke Multimeter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. EngPreventive Maintenance Checklist
Equipment : Baby Incubator Date : _____________
Merk : Air-Shields Period : _____________
Serial No. : ________________ Room : _____________
PPM CHECKLIST S/N Operational Checkout Procedure Pass Fail S/N Operational Checkout - Controller Pass Fail
1 Power Failure 1 Air Control Mode Of Operation 2 AC Power Cord 2 Air Set Temperature Alarm 3 VHA Stand 3 Air Auxiliary Probe 4 Hood Hinge and Latch operation 4 Baby Control Mode Of Operation 5 Access Panel Detent and Noise Level 5 Baby Set Temperature Alarm 6 Air Curtain Cover 6 Baby Temp Probe Fail Alarm 7 Main Deck 7 Air Flow Alarm 8 Iris Entry Port 8 Max Air Temperature 9 Access Panel Latches
10 Access Door Latch 11 Mattress Elevators 12 Mattress Tray Operation 13 Air Intake Micro filter 14 Oxygen Input Valve Filter 15 Air/Oxygen System
Test Equipment Used : DPM III, Fluke Multimeter
Remarks : ______________________________________________
Performed By:__________________ Verified By: __________________
BM.0308.46/1
Biomedical. EngPreventive Maintenance Checklist
Equipment : ECHO Date : __________________
Merk : GE Vivid 3 Period: __________________
Serial No. : Room : __________________
I. Physical ChecklistNo Item Pass Fail Description1 Table Console2 Probe Holders3 Control Panel4 Brake system5 Probe6 Monitor7 Cooling / Fans8 Keyboard Harness9 Power Cord10 Voltage Stabilizer11 Cover
12 Peripheral Input / output13 Printer
2. System Diagnostics ChecklistNo Item Pass Fail Description
1 Error Check2 Keyboard Function Check3 Color Monitor System Check4 Configuration Color Printer5 Calibration
Test Equipment Used : ______________________________________________
Remarks : ______________________________________________
Performed By:__________________ Verified By: ___________________
BM.0308.46/1
Biomedical. EngPreventive Maintenance Checklist
Equipment : USG Date : __________________
Merk : Periode : __________________
Serial No. : Room : __________________
I. Physical ChecklistNo Item Pass Fail Description1 Table Console2 Probe Holders3 Control Panel4 Brake system5 Probe6 Monitor7 Cooling / Fans8 Keyboard & Track Ball
9 Power Cord10 Voltage Stabilizer11 Cover12 Peripheral Input / output13 Printer
2. System Diagnostics ChecklistNo Item Pass Fail Description
1 Error Check2 Keyboard Function Check3 Color Monitor System Check4 Configuration Color Printer5 Calibration
Test Equipment Used : ______________________________________________
Remarks : ______________________________________________
Performed By:__________________ Verified By: ___________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Surgical Table Date : __________________
Merk : Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail
1 Preparation
2 Hydraulic System
3 Casters and Floor Locks
4 Controls
5 Electrical Checks
6 Table Rigidity
7 Final Test
Test Equipment Used : Fluke Multimeter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM 0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Obgyn Chair Date : __________________
Merk : Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Quantitative Test Pass Fail
1 Preparation
2 Hydraulic System
3 Casters and Floor Locks
4 Controls
5 Electrical Checks
6 Chair Rigidity
7 Final Test
Test Equipment Used : Fluke Multimeter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : ENT Unit Date : __________________
Merk : Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail
1 Chassis / Mounts / Fasteners
2 Controls / Switches
3 Fittings / Connectors
4 Cables / Accessories
5 Indicator Display
6 Warm Water System
7 Light System
8 Suction System
9 Mirror Warming
10 Compressed Air System
11 Stroboscope
Test Equipment Used : DPM III, Fluke Multimeter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : SPIROMETER Date : __________________
Merk : ________________________ Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail
1 Chassis / Mounts / Fasteners
2 Controls / Switches
3 Fittings / Connectors
4 Cables / Accessories
5 Indicator Display
6 AC-DC Adaptor
7 Transducer
8 Printer
Test Equipment Used : Fluke Multimeter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Dental Unit Date : __________________
Merk : Periode : __________________
Serial No. : ________________________ Room : __________________
NO Physical/Qualitative Test Pass Fail Description
1 Water Input Block
2 Air Input Block
3 Disinfection System
4 Drain
5 Hand Piece
6 Suction System
7 Amalgam Separator
8 Spittoon
9 Dental Chair Unit
10 Compresor Unit
11 Media
Voltages
Foot Control
Test Equipment Used : DPM III, Fluke Multimeter
Remarks : _____________________________________________________ _____________________________________________________
_____________________________________________________ _____________________________________________________
Performed by :_________________ Verified by :_________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : STERILIZER Date : _________________
Merk : Iwaki Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Quantitative Test Pass Fail
1 Preparation
2 Door Assembly
3 Solenoid Valve
4 Over temperature Controller
5 Air Vent (Steam)
6 Gauge
7 Chamber & Water Reservoir
8 Control Components
9 Final Test
Test Equipment Used : DPM III, Fluke Multimeter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Cauter Date : __________________
Merk : Martin________________ Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail
1 Chassis / Mounts / Fasteners
2 Controls / Switches
3 Fittings / Connectors
4 Cables / Accessories
5 Indicator Display
6 Electrode
7 Foot Switch
8 Surgical Output
Test Equipment Used : ESU Analyzer, Fluke Multimeter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Infusion Pump Date : __________________
Merk : _________________________ Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail
1 Main Unit/Pole Clamp (any damage)
2 Battery Power
3 Self Check
4 Charging System
5 Start/Stop/Silence Operation
6Tube Clamp
7 Occlusion detection
8 Delivery Rate Accuracy
9 Air-in-line Sensor
10 Drop Sensor
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Syringe Pump Date : __________________
Merk : _________________________ Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail
1 Self Diagnosis
2 Dial
3 Clear Σml
4 Buzzer Volume
5 Body weight mode
6 Syringe size detection
7 Nearly empty alarm
8 Occlusion
9 Flow rate accuracy
10 Battery
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : THORACIC DRAINAGE Pump Date : __________________
Merk : GOMCO model 6020 Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail Description
1 Pump Lubrication
2 Pump Cylinder
3 Solenoid Valve
4 Fan
5 Control Circuit
6 Collection Bottle and Cap Assembly
7 Manometer Tube Sterilization
8 Casing
9 Brake System
10
11
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : BREAST PUMP Date : __________________
Merk : MEDAP Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail Description
1 Pump Lubrication
2 Pump Cylinder
3 Solenoid Valve
4 Pressure Regulator
5 Control Circuit
6 Collection Bottle and Cap Assembly
7 Manometer Tube Sterilization
8 Casing
9 Brake System
10
11
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : ______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Liquid Oxygen Central Date :
__________________
Merk : Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mounts / Fasteners
2 Controls / Switches
3 Fittings / Connectors
4 Cables / Accessories
5 Indicator Display
6 Liquid Tank
7 Safety Valve
8 Regulator System
9 Alarm System
10 Pressure Meter
11 Reserve Cyllinder
Test Equipment Used : DPM III, Fluke Multimeter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Nitrous Oxide Central Date : __________________
Merk : Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mounts / Fasteners
2 Controls / Switches
3 Fittings / Connectors
4 Cables / Accessories
5 Indicator Display
6 Cyllinder Connector
7 Safety Valve
8 Regulator System
9 Alarm System
10 Pressure Meter
11 Reserve Cyllinder
Test Equipment Used : DPM III, Fluke Multimeter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Nitrogen Central Date :
__________________
Merk : Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mounts / Fasteners
2 Controls / Switches
3 Fittings / Connectors
4 Cables / Accessories
5 Indicator Display
6 Cyllinder Connector
7 Safety Valve
8 Regulator System
9 Alarm System
10 Pressure Meter
11 Reserve Cyllinder
Test Equipment Used : DPM III, Fluke Multimeter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Medical Air Equipment Date : __________________
Merk : ATLAS COPCO Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mounts / Fasteners
2 Controls / Switches
3 Fittings / Connectors
4 Cables / Accessories
5 Indicator Display
6 Reverse Cylinder
7 Safety Valve
8 Regulator System
9 Alarm System
10 Pressure Meter
11 Motor Compresstion
12 Oil Motor Compresstion
13 Filter Air
Test Equipment Used : DPM III, Fluke Multimeter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Vaccum Equipment Date : __________________
Merk : Ohmeda Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mounts / Fasteners
2 Controls / Switches
3 Fittings / Connectors
4 Cables / Accessories
5 Indicator Display
6 Vaccum Machine
7 Safety Valve
8 Regulator System
9 Alarm System
10 Pressure Meter
11 Oil Mechine
Test Equipment Used : DPM III, Fluke Multimeter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Anaesthetic Gas Scavenging Date :
__________________
System
Merk : Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mounts / Fasteners
2 Controls / Switches
3 Fittings / Connectors
4 Cables / Accessories
5 Indicator Display
6 Vaccum Machine
7 Alarm System
Test Equipment Used : DPM III, Fluke Multimeter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Mixer Date :
Merk : __________________ Period : _______________
Serial No. : _________________________ Room : Laboratorium
NO Physical / Qualitative Test Pass Fail Keterangan
1 Motor
2 Controls / Switches
3 Cables / Accessories
4 Line Indicator
Function test
Mixer Selector mode: FULL
TOUCH
Speed control : LOW
MEDIUM
HIGH
Test Equipment Used : Multi Meter, tool Set
Remarks : _____________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : TONOMETER Date :
Merk : Period :
Serial No. : _________________________ Room : Eye Center
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Controls/Switches
3 Fittings/Connectors
4 Cables/Accessories
5 Indicator Display
6 Bulb
7 Lens
8 Subflex
9 Airpulse
10 Set/Reset
11 Review
12 Demo
Test Equipment Used : Multi Meter, tool Set
Remarks : ________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Ultrasonic Biometer Date :
Merk : Period : __I_______________
Serial No. : ______________________ Room : Eye Centre
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Controls/Switches
3 Fittings/Connectors
4 Cables/Accesories
5 Indicator/ Display
6 Probe
7 Light Pen
8 Foot Pedal
9 Test Piece
10 Printer
11 Setting Up The Software
Test Equipment Used : Multi Meter, tool Set
Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM 0308.64/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Injector Contras Date :
__________________ Merk :
_________________________ Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail Description
1 Motor
2 Controls / Switches
3 Cables / Accessories
4 Line Indicator
5 Function test
6 Display menu
7 Syringe System
8 Injection Selector mode: Single
Multi
9 Flow injector
10 Pressure Limit Injector
11 Delay system 12 Key pad13 Hand switch
Test Equipment Used : Multi Meter, tool Set
Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM 0308.64/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Retinal Camera Date :__________________
Merk : Period : I
Serial No. : _________________________ Room : Eye Center
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Controls/Switches
3 Cables/Accessories
4 Indicator/Display
5 Camera
6 CPU
7 Printer
8
9
10
11
12
Test Equipment Used : Multi Meter, tool Set
Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : OPERATING LAMP Date :__________________
Merk : _________________________ Periode :__________________
Serial No. : _________________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mounts/Fasteners
2 Power / Adaptor Voltage
3 Cables /Accessories
4 Dimmer Regulator System
5 Brake Rotary System
6 Focus System
7 Cleaning
Test Equipment Used : Multi Meter, tool Set
Remarks : ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : MICROSCOPE Date :__________________
Merk/Type : _________________________ Periode :__________________
Serial No. : _________________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mounts/Fasteners
2 Power / Line Indicator
3 Cables /Accessories
4 Dimmer System
5 Bulb Lamp
6 Focus System
7 LENS Cleaning
8 Balancing
Test Equipment Used : Alcohol ,tool set
Remarks : ________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. EngPreventive Maintenance Checklist
Equipment : Surgical Table Date :______________________
Merk : Amsco/2080 Manual Period : _____________________
Serial No. : _________________________ Room : _____________________
PPM Check ListS/N Physical/Qualitative test Pass Fail S/N Pass Fail
1 Supported Table Top 8 Drive Crank Clutch Adjustment a. With base cover raised 9 Side Tilt Adjustment b. When base cover is not Raised 10 Selector Handle Locating Adjustme-
2 Floor Locks Ment a. Floor locks improperly adjusted 11 Friction Device on Lift Cylinder b.Binding of pedal linkage Adjustment c.Insufficient clearance between pedal 12 Kidney Elevator Handle And floor 13 Lateral Movement Stop Pin Adjus d.Pedal Sticks in Up Position Ment e.Pedal not Return To Maximum Up 14 Tredelenburg Hand Crank Position 15 Lateral Tilt Mechanism
3 Pump Pedal Adjustment 16 ShiftLever Modification 4 Hydraulic System 17 Lubrication
a.Oil Level b.Strainer c.Hydraulic Leakage
5 Table Elevation 6 Table Top Positioning 7 Lift Carriage Adjustment
Test Equipment Used : Multimeter, Tool Set
Remarks : ___________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : WARMING CABINET Date :__________________
Merk/Type : AMSCO Periode :__________________
Serial No. : _________________________ Room : ___________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mounts/Fasteners
2 Power / Line Indicator
3 Cables /Accessories
4 Heating Filament
5 Fan
6 Door Sensor
7 Display
8 Clean Cabinet
9 Heat Sensor
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Oxygen Transfer Date :
Merk : Merk :
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mounts / Fasteners
2 Fitting/connector
3 Regulator
4 Pressure meter
5 Pipe
Test Equipment Used : DPM III, Fluke Multimeter
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Scrub Station Date : ________________________
Merk : Amsco Period : ________________________
Serial No. : Room : ________________________
NO Physical / Qualitative Test Pass Fail Description
1 Cables/Accessories
2 Goose Neck/Rose Spray
3 Soap Spout
4 Hot Water
5 Cold Water
6 Timer
7 Soap Container
8 Temperature selector Handle
9 Water Knee Panel
10 Soap Knee Panel
11 Drain
12 Lubrication
Test Equipment Used : Multi Meter, tool Set, DPM III
Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Campimeter Date : ________________________
Merk : Humprey Period : ________________________
Serial No. : Room : ________________________
No. Bagian Alat Pemeriksaan Fisik Pemeriksaan Fungsi Keterangan Baik Tidak Baik Baik Tidak Baik
1. Badan /Permukaan2. Kabel/Konektor3. Saklar/Indicator4. Printer,key board,mouse5. Monitor6. Lampu 7. Filter Udara8. System self Cek9. System LOG10. Tegangan AC 220V
Test Equipment Used : Multi Meter, tool Set Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Tourniquet System Date : _________________
Merk : zimmer Period : _________________
Serial No. : Room : __________________
NO Physical / Qualitative Test Pass Fail Description
1 Cleaning
2 Inspection
3 Functional and Calibration Checks
4 Calibration:
Transducer Offset
Common Mode
Span Adjustment
Iteration Of Adjustment
5 Watchdog Timer Test
6 Leak Testing
7 Power Supply/ Battery Charger
8Battery Voltage Check and Battery Service
9 Overpressure Regulator
Test Equipment Used : Multi Meter, tool Set, DPM III
Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment :Cam Vision Stimulator Date : ________________________
Merk : Period : ________________________
Serial No. : Room : ________________________
No. Bagian Alat Pemeriksaan Fisik Pemeriksaan Fungsi Keterangan Baik Tidak Baik Baik Tidak Baik
1. Badan /Permukaan2. Kabel/Konektor3. Saklar/Indicator4. SLIDE Simulator5. Motor
Test Equipment Used : Multi Meter, tool Set
Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Cromoganic Kinetic SYS.Date :
________________________ Merk : Helena
Laboratories Period : ________________________
Serial No. : Room : Laboratorium
No. Bagian Alat Pemeriksaan Fisik Pemeriksaan Fungsi Keterangan Baik Tidak Baik Baik Tidak Baik
1. Badan /Permukaan2. Kabel/Konektor3. Saklar/Indicator4. Monitor5. Printer6. Unit7. Key Board8. Lampu 9. Filter Udara10. Pipet
Test Equipment Used : Multi Meter, tool Set Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Oxygen Flow meter Date : ________________________
Merk : Ohmeda/CIG Period : ________________________
Serial No. : Room : ________________________
No. Bagian Alat Pemeriksaan Fisik Pemeriksaan Fungsi Keterangan Baik Tidak Baik Baik Tidak Baik
1. Bola penunjuk2. Regulator 3. Botol Humidifier4. Volume output Pengukuran Terukur Toleransi
1 Lpm 0,95-1,052 Lpm 1,9-2,13 Lpm 2,85-3.154 Lpm 3,8-4,25 Lpm 4,75-5,2510 Lpm 9,5-10,515 Lpm 14,25-15,75
Test Equipment Used : Multi Meter, RT-200 Cal Analyzer,tool Set Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Suction Regulator Date : ________________________
Merk : Ohmeda Period : ________________________
Serial No. : Room : ________________________
No. Bagian Alat Pemeriksaan Fisik Pemeriksaan Fungsi Keterangan Baik Tidak Baik Baik Tidak Baik
1. Saklar On/off2. Regulator 3. Jarum /meter penunjuk4. Suction output Pengukuran Terukur Toleransi
- 100 mmHg 95-105- 200 mmHg 190-210- 300 mmHg 285-315- 400 mmHg 380-420- 500 mmHg 475-525- 600 mmHg 570-630- 700 mmHg 665-735
Test Equipment Used : Multi Meter, DPM III,tool Set Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Suction Regulator Date : ________________________
Merk : Ohmeda/ Thoracic Period : ________________________
Serial No. : Room : ________________________
No. Bagian Alat Pemeriksaan Fisik Pemeriksaan Fungsi Keterangan Baik Tidak Baik Baik Tidak Baik
1. Saklar On/off2. Regulator 3. Jarum /meter penunjuk4. Suction output Pengukuran Terukur
5 cmH2O 15 cmH2O 25 cmH2O 40 cmH2O 50 cmH2O 60 cmH2O Full Vac
Test Equipment Used : Multi Meter, RT 200,tool Set Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Suction Regulator Date : ________________________
Merk : Ohmeda Period : ________________________
Serial No. : Room : ________________________
No. Bagian Alat Pemeriksaan Fisik Pemeriksaan Fungsi Keterangan Baik Tidak Baik Baik Tidak Baik
1. Saklar On/off2. Regulator 3. Jarum /meter penunjuk4. Suction output Pengukuran Terukur Toleransi
- 20 mmHg 19-21- 60 mmHg 57-63- 80 mmHg 76-84- 120 mmHg 114-126- 160 mmHg 152-168- 200 mmHg 190-210
Full Vac
Test Equipment Used : Multi Meter, DPM III,tool Set
Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Autorefraktometer Date : ________________
Merk : Period : _________________
Serial No. : Room : __________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mounts
2 Control / Switch
3 Fitting / Connector
4 Cable / Accessories
5 Indicator / Display
6 Printer
Test Equipment Used : Multi Meter, tool Set, DPM III
Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : ____________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Head Lamp Date :
_________________ Merk :
Period : _________________
Serial No. : Room : __________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mounts
2 Control / Switch
3 Fitting / Connector
4 Cable / Accessories
5 Indicator / Display
6 Lamp
Test Equipment Used : Multi Meter, tool Set, DPM III
Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : ____________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : PHOROPTOR Date : _________________
Merk : Period : _________________
Serial No. : Room : _________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mounts
2 Control / Switch
3 Fitting / Connector
4 Cable / Accessories
5 Indicator / Display
6 Lamp
Test Equipment Used : Multi Meter, tool Set, DPM III
Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : ____________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Rehab Chair Date :__________________
Merk : Sinwanai Period :
Serial No. : _________________________ Room :
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Controls/Switches
3 Fittings/Connectors
4 Cables/accessories
5 Indicator/Display
6 Timer
7 Over loud
8 Speed adjusted
9 Motor
10
11
12
Test Equipment Used : Multi Meter, tool Set
Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Traction Machine Date :__________________
Merk : Triton Period :__________________
Serial No. : _________________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Controls/Switches
3 Fittings/Connectors
4 Cables/Accessories
5 Indicator/Display
6 Timer
7 Belt/Suspension
8 Patient Switch Activated
9 Static /Intermittent
10 Traction Progress
11
12
Test Equipment Used : Multi Meter, tool Set
Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Rigidometer Date :__________________
Merk : Uroan Period :__________________
Serial No. : _________________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Controls/Switches
3 Fittings/Connectors
4 Cables/Accessories
5 Indicator/Display
6 Sensor
7 Electric Charge
8 Battery
9 Computer Unit
10
11
12
Test Equipment Used : Multi Meter, tool Set
Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Ultrasound Therapy Date :__________________
Merk : Period :__________________
Serial No. : _________________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Power Cord
2 Fuse Drawer
3 Folding Handle
4 Power/Intensity Key
5 Output Calibration Key
6 Transducer Data Key
7 Transducer Head
8 Contrast Display
9 Transducer Cable
10 Cleaning Unit
11
12
Test Equipment Used : Multi Meter, tool Set
Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : EEG Date :__________________
Merk : Period :__________________
Serial No. : _________________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Overview
2 Power
3 Input Circuit and Amplifier
4 Operation
5 Activation
6 Disk Drive
7 Electrode Lead
8 Hard Disk and MO
9 Printer
10
11
12
Test Equipment Used : Multi Meter, tool Set
Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Tympanometer Date :__________________
Merk : Period :__________________
Serial No. : _________________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Display
2 Daily Calibration
3 Biological Calibration
4 Eartips
5 Probe TIP/Probe Head
6 Probe Lights
7 Probe Handle
8 Printer
9 Test Sequence
10
11
12
Test Equipment Used : Multi Meter, tool Set
Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Nebulizer Date :__________________
Merk : Period :__________________
Serial No. : _________________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Power line
3 Cables/Accessories
4 Ultrasonic Electrode
5 Timer
6 Sensor Water Level
7 Air Filter
8 Fan
9 Cleaning
10
11
12
Test Equipment Used : Multi Meter, tool Set
Remarks : ________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM 0308.64/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : FILM SCREEN Date :__________________
Merk : _________________________ Period :__________________
Serial No. : _________________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Bulb
7 Film Roller
8 Forward & Reverse System
9 Cover
Test Equipment Used : Multi Meter, tool Set
Remarks : ________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM 0308.64/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Washer Date :__________________
Merk : Period :__________________
Serial No. : _________________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Water Supply
7 Air Supply
8 Drain System
Test Equipment Used : Multi Meter, tool Set, DPM III
Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Light Source Date :__________________
Merk : _________________________ Period :__________________
Serial No. : _________________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Bulb
7 Fiber Optic
Test Equipment Used : Multi Meter, Tool Set, DPM III
Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Steam Boiler Date :__________________
Merk : AMSCO Period :__________________
Serial No. : _________________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Cable/Accessories
2 Pressure Steam
3 Connecting Pipe
4 Cold Water Inlet
5 Hot Water Inlet
6 Glass Level
7 Water Pump
8 Water Sensor Level
9 Heater
10 Check Valve
11 Drain
12 Pressure Meter
13 Safety Valve
Test Equipment Used : Fluke Multimeter, Tool Set
Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : OPTOTIF PROYEKTOR Date : _________________
Merk : Period : _________________
Serial No. : Room : _________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mounts
2 Control / Switch
3 Fitting / Connector
4 Cable / Accessories
5 Indicator / Display
6 Lamp
Test Equipment Used : Multi Meter, tool Set, DPM III
Remarks:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : ____________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Auto Fluid Balance Monitor Date
:__________________ Merk : Aquarius
Period :__________________
Serial No. : _________________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Self Test
7 Alarm signal
8 Heater
9 Battery
Test Equipment Used : Multi Meter, Tool Set, DPM III
Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Patient Warming System Date
:__________________ Merk :
Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Power/Line Indikator
3 Cable/Accessories
4 Heating Filament
5 Fan
6 Door Sensor
7 Display
8 Clean Cabinet
9 Heat Sensor
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Cast Cutter Date :__________________
Merk : Stryker Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Motor
7 Vacum
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Paracare Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Heater/Temperatur
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Intelect Advanced Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indikator/Display
6 Pad Elektrode
7 Intensity
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Blood Warmer Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Heater
7 Line Of Tubing Set
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Laser Argon Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Colling System
7 Laser Output
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Laser YAG Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Laser Output
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Static Bike Date
:__________________ Merk :
Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Tilt Table Lifeline Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Motor/Hydraulic System
7 Lubricating
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : CPM Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Drying Cabinet Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Fan
7 Heater
8 Cleaning
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : ID Camera Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Lamp
7 Motor
8 Cleaning
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Water Filter Amway Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Lamp UV
7 Filter
8 Cleaning
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Cassette Autoclave Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Control/Switches
2 Fitting/Connector
3 Cable/Accessories
4 Indicator/Display
5 Cleaning
6 Air Filter
7 Cassette
8 Reservoir
9 Wash Bottle
10 Lubricating/Changing Cassette seal
11 Temperature
12 Aluminium Antena & Holder
Test equipment used :.._____________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : EMG Date :__________________
Merk : Period :__________________
Serial No. : _________________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Overview
2 Power
3 Input Circuit and Amplifier
4 Operation
5 Activation
6 Disk Drive
7 Electrode Lead
8 Hard Disk
9 Printer
10
11
12
Test Equipment Used : Multi Meter, tool Set
Remarks : ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Bilirubinometer Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Power/Line Indikator
3 Cables/Accessories
4 Bulb Lamp
5 Cleaning
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Blood Bank Date :__________________
Merk : Sanyo Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Controls/Switches
3 Fitting/Connector
4 Indikator/Display
5 Cable/Accessories
6 Temperature
7 Freezer
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Centrifuge Date
:__________________ Merk :
Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Cables/Accessories
3 Indicator/Display
4 Speed
5 Start Botton
6 Stop Botton
7 Lid Botton
8 Timer
9 Decelerate Botton
10 Door Switch
11 Imbalance
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Ultrasonic Cleaner Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Cables/Accessories
3 Power/Adaptor
4 Rack system
5 Indikator
6 Timer
7 Cleaning
8
9
10
11
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Oxicom Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Cables/Accessories
3 Fittings/Connectors
4 Control/Switches
5 Indikator display
6 Sensor
7
8
9
10
11
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Unit Endoscopy Date :__________________
Merk : OLYMPUS Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Control / switch
2 Fitting and connectors
3 Cable and accessories
4 Indicator / display
5 Suction System
6 Xenon lamp
7 Gastro scope
8 Colon scope
9 Broncos scope
10 Printer
11 White Balance
12 Monitor
Test Equipment Used : ______________________________________________________________
Remarks : ______________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Polymerization Light Date :__________________
( Light Curing )
Merk : ______________________ Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mount / Fasteners
2 Control / Switches
3 Fitting / Connector
4 Indicator / display
5 Cable / Accessories
6 Hand Piece
7 Lamp
Test Equipment Used : ______________________________________________________________
Remarks : ______________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Infant Warmer Date :__________________
Merk : ______________________ Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mount / Fasteners
2 Control / Switches
3 Fitting / Connector
4 Indicator / display
5 Cable / Accessories
6 Probe
7 Heater
8 Suction System
9 Flow meter O2
10 Bassinet Tilt Control
11 Side and End Panel
12 X-Ray Tray
13 Examination light
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Short Wave Diathermy Date
:__________________
Merk : ______________________ Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Power cord
2 Fuse drawer
3 Power output meter
4 Power adjust step
5 Electrode
6 Electrode cable
7 Timer + indicator
8 Electrode holding
9 Wheel + Brake
10
11
12
13
Test Equipment Used : ______________________________________________________________
Remarks : ______________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Microwave Diathermy Date :__________________
Merk : ______________________ Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Power cord
2 Fuse drawer
3 Power output meter
4 Power adjust step
5 Electrode
6 Electrode cable
7 Timer + indicator
8 Electrode holding
9 Wheel + Brake
10
11
12
13
Test Equipment Used : ______________________________________________________________
Remarks : ______________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Electric Stimulator Date :__________________
Merk : ______________________ Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mount / Fasteners
2 Control / Switches
3 Fitting / Connector
4 Indicator / display
5 Cable / Accessories
6 Brake system
7 Vacuum System
8 Pad electrode
9 Water reservoir
10 Intensity
11
12
13
Test Equipment Used : ______________________________________________________________
Remarks : ______________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Infra Red Lamp Date :__________________
Merk : ______________________ Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mount / Fasteners
2 Control / Switches
3 Fitting / Connector
4 Indicator / display
5 Cable / Accessories
6 Timer
7 Lamp
8
9
10
11
12
13
Test Equipment Used : ______________________________________________________________
Remarks : ______________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Cusa Unit Date :__________________
Merk : ______________________ Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mount / Fasteners
2 Control / Switches
3 Fitting / Connector
4 Indicator / display
5 Cable / Accessories
6 Pump Irrigation
7 Suction
8
9
10
11
12
13
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Bor Tulang Date
:__________________
Merk : ______________________ Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mount / Fasteners
2 Power Line Indicator
3 Fitting / Connector
4 Accessories
5 Gas Supply
6 Motor System
7 Drill Rotating
8
9
10
11
12
13
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Electronic Laparofator Date
:__________________
Merk : ______________________ Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mount / Fasteners
2 Control / Switches
3 Fitting / Connector
4 Accessories
5 Gas Supply
6
7
8
9
10
11
12
13
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Nerve Detector Date :__________________
Merk : ______________________ Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis / Mount / Fasteners
2 Control / Switches
3 Fitting / Connector
4 Accessories
5 Battery
6
7
8
9
10
11
12
13
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Suction Pump Unit Date : __________________
Merk : Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical / Qualitative Test Pass Fail Description
1 Pump Lubrication
2 Pump Cylinder
3 Valve
4 Regulator
5 Control Circuit
6 Collection Bottle and Cap Assembly
7 Manometer Tube Sterilization
8 Casing
9 Brake System
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : SPIROMETRI Date : __________________
Merk : _________________________ Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical/Quantitative Test Pass Fail
1 Chassis / Mounts / Fasteners
2 Controls / Switches
3 Fiitings / Connectors
4 Cables / Accessories
5 Battery / Charger
6 Indicator / Display
7 Alarm / Audible Signals
8 Tranduser
9 Cabel + Conector Tranduser
10 Beep
11 Calibrasi
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM 0308.4
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Cell Dyn 3500 Date :__________________
Merk : Abbott Period :__________________
Serial No. : ______________________ Room :_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Cables/Accessories
3 Fittings/Connectors
4 Control/Switches
5 Indikator display
6 Tubings
7 Valve
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Axsym System Date :__________________
Merk : Abbott Period :__________________
Serial No. : ______________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Cables/Accessories
3 Fittings/Connectors
4 Control/Switches
5 Indicator/ display
6 Monitor
7 Printer
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Bactec Date :__________________
Merk : Becton Dickinson Period :__________________
Serial No. : ______________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Cables/Accessories
3 Fittings/Connectors
4 Control/Switches
5 Indikator display
6 Heater
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : ENTONOX Date :__________________
Merk : Jono Mark II Period :__________________
Serial No. : ______________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Fittings/Connectors
3 Oxygen Accessories
4 Nitrous Oxide Accessories
5 Mixer (%)
6 Test Lung
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Heart Lung Machine Date : __________________
Merk : Stockert S3 Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical/Quantitative Test Pass Fail
1 Chassis/Mounts /Fasteners
2 Controls/Switches
3 Fiitings/Connectors
4 Cables/Accessories
5 Battery/Charger
6 Indicator/Display
7 Alarms/Audible Signals
8 Pump
9 Pressure Meter
10 Power Suplay Voltage (5 V, 12 V, 15 V dan 24 V)
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Anaesthetic Machine Date : __________________
Merk : _________________________ Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical/Quantitative Test Pass Fail
1 Chassis/Mounts /Fasteners
2 Controls/Switches
3 Fittings/Connectors
4 Cables/Accessories
5 Battery/Charger
6 Indicator/Display
7 Gas Supply
8 Bellows Rubber
9 Pressure Meter
10 Gas Monitoring System
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : IABP Date
:__________________ Merk : Datascope
Period :__________________
Serial No. : ______________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Cords and Cables
2 Controls and Switches
3 Safety Disk
4 Cooling Fan
5 Doppler
6 Pneumatic Compartment
7 Fill Assembly
8 Motor Compartment
9 Electronic Panel
10 Helium Supply
11 Battery Back Up
12Calibrate System and Perform Functional Test
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Oximeter Date : __________________
Merk : _________________________ Period : __________________
Serial No. : _________________________ Room : __________________
NO Physical/Quantitative Test Pass Fail
1 Chassis/Mounts /Fasteners
2 Controls/Switches
3 Fittings/Connectors
4 Cables/Accessories
5 Battery/Charger
6 Indicator/Display
7 SPO2 Sensor
Test Equipment Used : ________________________________________________________
Remarks : ________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : CPAP Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Doctor Operating Chair Date
:__________________ Merk :
Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Preparation
2 Hydraulic System
3 Caster and Floor Locks
4 Controls
5 Electrical Checks
6 Chair Rigidity
7 Final Test
8
9
Test Equipment Used : ______________________________________________________________
Remarks : ______________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Slit Lamp Date
:__________________ Merk :
Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Lamp
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Dental X-Ray Date :__________________
Merk : Period :__________________
Serial No. : _______________________ Room :__________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Lubrication Rel Up/Down
7 Mechanical Checks
8 Cleaning
9 Functional Checks
Setting Pada Alat Terukur Koreksi
KVp Second KVp Second KVp Second
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Uroflow
Merk : Date :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/Display
6 Volume Transducer
7 Printer
8 Measurement cup
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : AUDIOMETER Date :__________________
Merk : Period :__________________
Serial No. : _______________________ Room :__________________
PPM Check List PPM Check ListS/N Physical/qualitative test Pas
sFail S/N Pas
sFail
1 Power on/off 18 LED Read Out of Frequency Selected2 Present/Interrupt Switch (2) 19 LED Read Out Of Intensity Selected3 Left/Right Earphone Selector 20 LED Indicator (subject Respond)4 Stimulus on (interrupt) 21 LED Indicator (Stimulus Present)
Stimulus off (Present) 22 LED Indicator of Active Test 5 Automatic Pulsing Earphone or Masking For Bone6 Frequenchy Modulation (FM) 23 LED indicator Stimulus On/Off7 Test Signal 24 LED Idicator of Auto Pulsign8 + 10 dB Switch 25 LED Indicator for FM9 Tone Stimulus Select 26 LED indicator for masking level
10 Tape/Microphone Select intensity11 Speaker Select 27 LED indicator of +10 dB12 + 2.5 Select 28 LED Indicator Earphone/Bone13 Talk Forward 29 LED Indicator of +2.5 dB14 Frequency Select Control
Doal30 LED Indicator Speaker Selectionu
15 Intensity Control Dial 31 LEDIndicator of Tone Stimulus
16 Masking Level Control 32 LED Indicator of Tape or 17 Test Microphone Level
ControlMicrophone Stimulus Selected
33 Speech Level VU meter
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
LAPORAN PEMERIKSAAN ALAT BARU
Equipment : Mesin Hemodialisa
Merk : Date :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Working Hours
2 Flow 300 (Dialisis)
3 Flow 500 (Dialisis)
4 Flow 800 (Dialisis)
5 Blood Leak
6 Dimnes
7 Blood Pump Rate
8 Check Temperature
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Resuscitator Date
:__________________ Merk :
Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Fibrintimer Date
:__________________ Merk :
Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Rotator Date
:__________________ Merk :
Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Water Bath Date
:__________________ Merk :
Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6 Temperature
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Thermasealerr Date
:__________________ Merk :
Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Retraction Date
:__________________ Merk :
Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Histocantre Date
:__________________ Merk :
Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Croytom Date
:__________________ Merk :
Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Chiller Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room:_________________
Physical / Qualitative Test Pass Fail
NO Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Lemari Asam Date
:__________________ Merk :
Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment :Thermasealler Date
:__________________ Merk :
Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment :Cryotome Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment : Clinitex Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment :Radrometer Date
:__________________ Merk :
Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1
Biomedical. Eng
Preventive Maintenance Checklist
Equipment :Architect Date :__________________
Merk : Period :__________________
Serial No. : ______________________ Room:_________________
NO Physical / Qualitative Test Pass Fail Description
1 Chassis/Mounts/Fasteners
2 Control/ Switches
3 Fitting/Connector
4 Cable/Accessories
5 Indicator/display
6
7
8
9
Test Equipment Used : ______________________________________________________________
Remarks : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Performed by : _____________________ Verified by : _______________________
BM.0308.46/1